The present invention relates to medical equipment and more particularly to surgical apparatus for suturing organs, such as intestines, stomach, vessels or the like, with metal staples. The proposed apparatus is intended for suturing organs "end-to-end", "end-to-side" and "side-to-side" with the working parts of the apparatus disposed outside the organ being sutured.
The proposed apparatus may be used, specifically, for suturing the organs of the alimentary tract, for example, the intestines, with a one-tier or two-tier buried suture.
Known in the art is a surgical apparatus for suturing organs with metal staples "end-to-end", "end-to-side" and "side-to-side" with the working part of the apparatus disposed outside the organ being sutured (cf. U.S. Pat. No. 3,973,709). This prior art apparatus comprises two attachable clamps each having two jaws for clamping and fixing the organ being sutured. The clamps are detachably joined together so that the mating plane of the jaws of each clamp is perpendicular to the matingj plane of the clamps.
Mounted on the jaws of the clamps are dies with grooves for clinching staples, as well as magazines with slots for the staples and pushers. The magazines and dies interacting at the moment of suturing are situated on jaws of different clamps. The apparatus is furnished wih wedge drives for setting the pushers in motion.
Mounted also on the jaws of the clamps is a means for grasping and fixing the walls of the organ being sutured. It is made in the form of movable casings with toothed fixing members situated along the jaws at an equal pitch. On each of the jaws the casings are set in guides made as closed inclined slots worked in struts secured on the jaws, and cylindrical pins inserted into the slots and secured on the lateral ends of each casing. The guides provide for the limited movement of the casings in a plane perpendicular to the mating plane of the jaws and that of the clamps.
Every casing can take two extreme positions. In one, the forward position, corresponding to the moment of clamping and grasping the walls of the organ or organs being sutured, the tips of the teeth of the fixing members lie between the mating surfaces of the jaws of the clamps and at some distance in front of the mating surfaces of the clamps. In the other, extreme backward position, the tips of the teeth lie at some distance from the mating surfaces of the jaws of the clamps and approximately in the plane of the mating surfaces of the clamps. The tips of the teeth of the apparatus known in the art set only for one, constant suturing clearance between the interacting magazines and dies of the opposite clamps.
The prior art apparatus comprises a lock locking the movable casings in the forward position made in the form of a strip with stops pressing a casing to the trasversal wall of the closed guides. The casing is released from the locked position by disengaging the stops from the casing.
Cam lobes on each casing of the clamp serve for setting the movable casings in the backward position and interact with the corresponding cam lobes situated or the casings of the opposite clamp.
By means of cam lobes, the movable casings can be set in the backward position only after the clamps are joined and locked in position with a definite constant clearance between them. If this clearance is increased or the clamps are uncoupled the movable casings are shifted in the forward position and the toothed members fixing the walls of the organs get within the zone between the juxtaposed magazines and dies.
The clamps of the prior art apparatus are connected one with the other by means of a detachable joint at one end and rotatable hooks at the other. The rotatable hooks can fix the clamps at the moment of suturing only at one constant clearance in the mating plane between them.
The toothed elements fixing the walls of the organ in the prior art apparatus may have a variation of embodiments. An embodiment thereof comprises toothed elements in the form of needle-like teeth straight and bent in the longitudinal direction. The fixing teeth are disposed on strips set in movable casings along the jaws of the clamps. The strips with direct teeth are fixedly secured in the casings, while the strips with the bent teeth are movable in the longitudinal direction. As the movable strips move relative to the immobile ones the walls of the organ is grasped between the jaws of the clamp, by the paired fixing teeth. The movement of the strips with the bent teeth is carried out, by means of guides connected therewith, secured on the strips of the locks locking the movable bodies in the forward position.
The jaws of each clamp are hinged together.
For joining the jaws when compressing an organ to be sutured, each clamp comprises a figured spring plate, fastened with one end in one of the clamp jaws, and stepped recesses situated on the other jaw and interacting with the other end of the spring by one of its recesses depending on the thickness of the walls of the organ being clamped.
Scales on the clamp jaws serve for the mutual juxtaposition of the organ or organs being sutured in a direction longitudinal relative to the jaws.
The operation of the prior art apparatus is of the same type both when suturing organs "end-to-end" and when suturing them "end-to-side" and "side-to-side".
Before using the apparatus the clamps are parted. The strips of the locks of the movable casings, hooks and the drives of the pushers are set in the initial position.
One of the portions to be sutured is compressed between the jaws of one clamp within the scale for mutual juxtaposition of the organs to be sutured. When the organ is clamped the spring plate closes the jaws of the clamp.
Then the walls of the compressed organ are grasped and secured by means of the fixing members. For this the locking strips of the movable casings, are moved into the forward position. The guides secured on said strips shift the strips with the bent teeth which pierce the walls of the organ as their tips join the paired straight teeth. As the walls are being grasped the casings locked in the forward position are released.
In accordance with the position of the first area to be sutured relative to the scales of the first clamp, so the second area to be sutured is mounted and clamped according to the scales of the second clamp. Then the walls of the organ are secured and the movable casings are released from their locks as was done when handling the first clamp.
After dissecting the part of the organ to be removed along the frontal surface of the casings the clamps are joined. For this the axle and aperture of the detachable joint are superposed, the jaws of the clamps are approximated and the hooks are turned completely, rigidly connecting the clamps. A definite constant suturing clearance is thereby set between the jaws, and, consequently, between the conjugated magazines and dies. During the connection of the clamps the cam lobes of the movable casings of the means for grasping and fixing the walls of the organs to be sutured press against each other and withdraw the casings into the backward position only after the full turn of the hooks, placing the fixed edges of the walls into the suturing position.
By moving the wedge drives of the pushers, the staples are forced out of the magazine slots and the walls of the organ are sutured with an everted suture. Then the strips of the locks of the movable bodies are drawn backwards, due to the paired straight and bent fixing teeth which are drawn apart releasing the walls of the fixed organ.
Then the hooks are set in the initial position. The clamp jaws are drawn apart for which the stepped recesses of the spring are disengaged. Following that the apparatus is withdrawn from the surgical wound.
After applying the first tier of sutures with the aid of the prior art apparatus, the second tier of buried (invaginating) serous-muscular sutures are manually applied when suturing an organ or organs of the alimentary tract. A majority of surgeons regard the application of the second tier of buried sutures to be worthwhile.
The second tier of sutures is applied manually in individual interrupted buried sutures, one by one, first on the anterior wall of the sutured organ. The sutured organ is turned out in such a manner that the posterior wall of the organ faces the opening into the surgical wound. Then, the buried sutures are applied one by one to the posterior wall and the organs sutured with a two-tier buried suture are turned into the normal position.
The design of the prior art surgical apparatus does not provide for the synchronous movement of the interacting opposite casings of the means for grasping and fixing the walls of the organ to be sutured from the forward into the backward positions when joining and locking the clamps. Such movement takes place with some lagging behind of one casing in relation to the other, owing to the unequal friction in the guides of the casings of the opposite clamp jaws, errors in the shape and mutual situation of the cams, acting upon each other when the clamps are joined, and also the possibility of unequal preliminary shift of the casings towards the jaws after the walls of the organs are secured and the part to be removed is cut off along the jaws of the separate clamps. As a result of this, the edges of the walls being juxtaposed for suturing, protrude beyond the fixing members of the casings of one clamp, are set in the position of suturing earlier than the edges of the walls, projecting beyond the fixing members of the opposite casing of the other clamp.
Owing to this the distance from the resection line of the sutured edges of the walls to the suture is unequal before suturing and, consequently, the juxtaposition of the edges of the walls of the sutured organ is not accurate enough.
Nor does the design of the prior art apparatus provide for suturing organs with different clearances between the magazines and the dies, that is, for adjusting the clearance of the deformed staples according to the thickness of the walls being sutured. The setting of the movable casings of the means for grasping and fixing the walls of the organ to be sutured from the forward into the backward position takes place in the prior art apparatus only upon the complete rotation of the hooks, securing a quite definite, single clearance between the joined clamps. Only given this clearance the fixing members can be set in the position enabling the suturing of the walls of the organ or organs. At an increase of the clearance the movable are shifted towards the forward position, while the fixing members get into the zone between the interacting magazines and dies.
The design of the prior art apparatus does not provide for suturing the walls of organs end-to-end with contact of the walls along the surface of the cut and suturing with a suture inverted relative to the cavity of the organ with contact between the external surfaces of the walls of the organ, as used in surgical practice.
Nor does the design of the prior art apparatus allow its use for applying a second tier of buried staple sutures, used for suturing the organs of the alimentary tract. The means for grasping and fixing the walls of the organs, whose casings are situated in the backward position only after joining and securing the clamps at a constant clearance, does not provide for burying the edges of the fixed walls of the organs or the first tier of sutures, or for placing the walls of the organs above it into the suturing position in order to apply a second tier of sutures.
It should also be borne in mind that the design of the prior art apparatus does not provide for the adjustment of the suturing clearances. This is essential when placing the second tier of sutures with the use of an apparatus for placing the first tier of sutures, since the thickness of the walls being juxtaposed for suturing through the serous-muscular layers when placing the second tier of sutures differs substantially from the thickness of the edges of the walls set between the magazines and the dies when the first tier of sutures is being placed.
Another disadvantage of the prior art apparatus is the necessity of placing the second tier of buried sutures by hand, by creating a sequence of individual interrupted sutures. This is labor-consuming and takes considerable time.
Due to the fact that the casings for grasping and fixing the walls of the organ are set in the backward position only after the clamps are joined, the prior art apparatus does not provide for suturing organs during resections aimed at the complete closure of the lumen of organs.